Treatment Should Be Tailored to Each Individual, Involve Team-Based Approaches

WASHINGTON — There is no single therapy or universal treatment approach that will help all veterans experiencing chronic multisymptom illness (CMI), says a new report from the Institute of Medicine. The U.S. Department of Veterans Affairs should customize care with an array of therapies tailored to each former service member's needs, said the committee that wrote the report.

VA should harness the potential of existing programs such as post-deployment patient-aligned care teams (PD-PACTS) to improve CMI care, the report added. The department should also pursue a new strategy of creating "CMI champions" to help its health care providers better serve patients with complex symptoms and needs, the committee said.

To boost the department's ability to identify former service members with CMI, VA's electronic health record should prompt health care providers to ask patients about symptoms that characterize CMI. Veterans should undergo a comprehensive health examination immediately after they leave active duty, and the results of these exams should be available to clinicians both within and outside the VA health system to ensure continuity of care.

"Based on the voluminous evidence we reviewed, our committee cannot recommend using one universal therapy to manage the health of veterans with chronic multisymptom illness, and we reject a 'one size fits all' treatment approach," said committee chair Bernard M. Rosof, chair, board of directors, Huntington Hospital, Huntington, N.Y. "Instead, we endorse individualized health care management plans as the best approach for treating this very real, highly diverse condition."

Written as part of IOM's congressionally mandated Gulf War and Health series, the report presents a comprehensive evaluation of the various treatments for CMI and recommends the best approaches to managing veterans' care. The committee defined CMI as the presence of a spectrum of chronic symptoms in at least two of six categories -- fatigue, mood and cognition, musculoskeletal, gastrointestinal, respiratory, and neurologic -- experienced for at least six months.

CMI shares characteristics with other conditions marked by chronic, medically unexplained symptoms, but its symptoms are not fully captured by other recognized syndromes. Formerly dubbed Gulf War Syndrome, CMI affects roughly one-third of veterans of the 1991 Persian Gulf War. Many personnel who served in the more recent conflicts in Iraq and Afghanistan have reported similar symptoms. In comparison, conditions involving chronic, unexplained symptoms affect roughly one-fourth of the general U.S. population. The cause or causes of CMI probably will never be fully determined, the committee said, but this does not undermine the legitimacy of vet­erans’ reports of symptoms.

To help tailor care to individual needs, VA should establish a CMI-focused PD-PACT, the report says. PD-PACTs represent a relatively new model of care within the VA health system that involves managing patients' care through teams of providers that may include a project manager, primary care physicians, nurses, mental health cli­nicians, social workers, and other specialists.

The committee's review of treatment options determined that many veterans may benefit from cognitive behavioral therapy and from medications such as selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors. Other interventions and approaches, such as biofeedback, acupuncture, St. John’s wort, aerobic exercise, motivational interviewing, and multimodal therapies, could hold promise but lack robust scien­tific evidence of their effectiveness. VA should fund and conduct studies of these interventions to determine their usefulness for CMI.

Creating the new position of "CMI champion" at each VA medical center would provide clinicians an internal resource of information and advice about how best to serve patients with CMI, the report says. Champions should be knowledgeable about the variety of therapeutic options, have easy access to a team of consulting clinicians, and be trained in commu­nication skills.

The study was sponsored by the U.S. Department of Veterans Affairs. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides objective, evidence-based advice to policymakers, health professionals, the private sector, and the public. The Institute of Medicine, National Academy of Sciences, National Academy of Engineering, and National Research Council together make up the private, nonprofit National Academies. For more information, visit http://national-academies.org or http://iom.edu. A committee roster follows.